Telestroke Alaska Evidence Based Care Across the Great Frontier

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1 Telestroke Alaska Evidence Based Care Across the Great Frontier Presented by Dr. Christie Artuso Director, Neuroscience Services Providence Alaska Medical Center 1

2 2

3 Financial Disclosures I am a speaker for Genentech through the Activase Speaker s Bureau. I am a faculty member at the University of Phoenix facilitating graduate and undergraduate coursework in the Healthcare Sciences Division. I have no financial disclosures related to this presentation for the Northwest Regional Telehealth Resource Center 3

4 Learning Outcomes Define telemedicine as a technology used to deliver evidence-based care for patients with an acute focal neurologic deficit. Identify three outcomes associated with the use of telemedicine to deliver care in rural settings Identify three challenges faced when initiating a telemedicine program for both hub (central support) and spoke (recipient) of services 4

5 History of Technology Years it took to reach a market audience of 50 million: Radio 38 years.. Television 13 years.. Internet 4 years. Ipod 3 years Facebook 2 years.. 5

6 The Growth of Technology.. The number of internet devices in 1984 was about 1,000.. The number of internet devices in 1994 was about 1,000,000 The number of internet devices in 2008 was about 1,000,000,000.. According to Forbes (2012) 8.7 billion 6

7 The Future of Healthcare? Nationally, the top ten In-demand jobs in 2010 did not exist in 2004 We are currently preparing children for jobs that don t yet exist Using technologies that have yet to be invented In order to solve problems that we don t yet know about.. 7

8 Technology s Role.. Technology continues to advance and facilitate improved quality in the delivery of healthcare in a dynamic and complex environment. 8

9 Telemedicine defined. The use of telecommunication and information technology to medical information and services Store and forward Remote monitoring Real-time interactive (video/audio) 9

10 Clinical Transformation Mobile technologies Mature electronic health records [EHR] Clinical decision support systems Continuous telemedicine / telehealth monitoring Shortages of medical specialists Increased complexity of care as population ages 10

11 Why Stroke? Telestroke 2005 American Stroke Association developed Stroke Systems of Care emphasizing linkages rather than silos Coordinated approach Improve access to highly skilled care & services 30% incidence of mis-diagnosis? Implement latest evidence-based guidelines Early intervention 11

12 Why Alaska? 586,412 square miles distance, cost of transport Geographic barriers, extreme weather, vast distances Population 722,718 (40% in Anchorage) 31 healthcare facilities [3 largest in Anchorage] ; 11 community hospitals; 13 critical access hospitals; 7 specialty or military hospitals 25% of Alaskans live in communities of < 1000 people 75% Alaskan communities not connected by roads to a hospital 12

13 Understanding Alaska. 13

14 Geographic Penalties The quality of stroke care is dependent upon the hospital that you go to If you live in a rural area or underserved acute stroke care area you will NEVER receive the only FDA approved pharmaceutical agent for treating stroke There is a GEOGRAPHIC penalty associated with stroke outcomes.. 14

15 Why Stroke in Alaska? Stroke death rate is 6% higher than national averages National death rate is decreasing yet the Alaska death rate stays the same Higher smoking 22% Higher overweight / obesity 63% Higher rate of elevated 31% 15

16 Barriers associated with Telemedicine? Defining the specialty Licensure and liability Developing policies recognizing privacy and security Simplifying the process (actual consult) Sustainability financial models 16

17 Advantages Access to care Decreased transportation costs Improved care decisions Access to specialists E-consultation / telestroke / teletrauma / telepsychiatry Improved quality improved patient outcomes Monitoring E-consultation with recommendation Education and training Access to conferences / expert consultation 17

18 Outcomes? End 2007 over 12 telestroke programs in Europe 18 Hub hospitals & 77 spoke hospitals 20,000 patients evaluated 2200 telestroke consults per year 18% systemic thrombolysis 2006 World Health Organization Helsingborg Declaration on European Stroke Strategies Access to continuum of care Acute stroke units Rehabilitation Secondary prevention 18

19 Disadvantages Lack of resources High infrastructure costs Rapid evolution of technology Licensure / credentialing Reliability Changing infrastructure and technology Rural communities Available bandwidth Trust / distrust Perception of concept Responsibility vs. accountability Legal limitations 19

20 Project Framework: 1. What are the essential components of a state-wide Stroke Center of Excellence? 2. What are the essential components of a telemedicine stroke program? 3. Which hospitals in the State of Alaska have the capability to transmit and receive the internet signals necessary for remote telemedicine support? 4. What hardware and software requirements are necessary? 5. What financial support will be required? 20

21 What are the essential components of a state-wide Stroke Center of Excellence? Provision of full range of services for all or most of the population in a community Support for evidence-based care Clinical consultation for evaluation, triage and transfer Provision of required diagnostic tests and treatment Public education Risk factors Primary prevention 21

22 What are the essential components of a telemedicine stroke program? Resources to support infrastructure Two way audio-video with reliable connectivity 24 hour qualified physician (specialist) support at the Hub CT scan at spoke (based on hub / spoke model) Appropriate provider(s) / telepresenter at spoke 22

23 Current Applications Hub and Spoke Model of Care 23

24 Which hospitals in the State of Alaska have the capability to transmit and receive the internet signals necessary for remote telemedicine support? Analysis of hospitals throughout the State of Alaska asking the following: Location Internet access / type DICOM Compatible CT Scanner Number of inpatient beds Estimated emergency department visits per year Approximate number of patients with stroke per year (based on national statistics) 24

25 Primary Spoke Hospitals Bartlett Regional Hospital Juneau, AK [55 beds] Providence Kodiak Island Medical Center Kodiak Island, AK [CAH - 22 beds] Providence Seward Medical and Care Center Seward, AK [CAH - 12 beds] Central Peninsula General Hospital Soldotna, AK [70 beds] Providence Valdez Medical Center Valdez, AK Providence Alaska Medical Center Anchorage, AK (Hub) [CAH 4 beds] 25

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27 What hardware and software requirements are necessary? Type of internet connection wireless vs. wired? High definition camera with accessible software Laptop vs. mobile computer station Tech support Electronic records DICOM image sharing Remote PACS 27

28 Infrastructure? Fiber Optic Lines connecting some communities Wireless / web-based access in towns often DSL or dial-up? Bandwidth Portable vs. wired? Technical support? Travel and education? Receptiveness 28

29 Options eicu in process not available yet Wireless cart (REACH Health, Inc.) Robot (RP-7) In Touch PolyCom / Global Med hardware only Homegrown? 29

30 What financial support will be required? Cost of technology and connectivity Costs of education and training Costs associated with hardware maintenance and replacement Estimated cost for a three-year program launch in Alaska ~ $995,000 not including physician fees, patient transport or direct medical costs. 30

31 Financial Planning You may not get what you want but often you get what you measure! Revenue model Show clear revenue management Cost saving model Show the benchmark and a method to clearly measure the savings Strategic model Show a way to measure strategic contribution 31

32 Current Technologies 32

33 Technology s Impact on the Healthcare System. Clinical information systems [Electronic Medical Records] Computer-chip based clinical monitoring devices Advanced applications with remote, wired and wireless communication devices [telemedicine; eicu] Clinical decision support software [ImPACT] [eicu] 33

34 Implications Impact on nursing / medical practice Change in how we deliver medical care Change in what we expect from the healthcare system Changes in community perceptions Changes in provider / nurse / patient relationship 34

35 Developing a Program Establishing the vision and align with organization s vision and mission Assess the community(ies) [gather data] Define program objectives Survey infrastructure Identify needs ($$$$, technology, support) Develop success metrics Measure outcomes 35

36 Establishing a Vision Critical Questions Where do you want to go? How will the journey affect your objectives? How is your vision for the telemedicine program aligned with your organization s overall vision? Is your program objective the same as the organization s objective for the program? 36

37 Vision Providence Health & Services, Alaska As People of Providence we reveal God's love for all, especially the poor and vulnerable, through our compassionate service. Neuroscience Service Line Recognized as Alaska s premier Neuroscience Center of Excellence providing collaborative services designed to meet the needs of the state. Telestroke Program To provide collaborative evidence-based stroke care that meets the needs of Alaskans 37

38 Program Objectives Identify 7 potential spoke sites in Alaska Build relationships with staff / leaders in those organizations Implement telemedicine (stroke) at 7 sites Maintain robust support Identify subsequent sites for implementation Reevaluate utilization and cost at 24 months Develop ongoing plan for additional telemedicine utilization / implementation 38

39 Assessing the Community What needs would the program meet in the community? What services would be provided? Who would use the service? What technology is available? What type of connectivity would be effective and reliable? 39

40 Impact on Providers and Nursing Plan and Assure Effective Training Workflow Delivery of patient care Education Expectations Are you the champion? 40

41 Impact on Patient Outcomes Ask appropriate questions What were the objectives of the program Did the program develop the infrastructure necessary to achieve the goals Was appropriate education provided What outcomes are expected How will you measure the outcomes 41

42 Steps to Success Clearly define the objectives of the program Align program objectives with organization s objectives Outline the results / outcomes that you hope to accomplish Short and long term goals with metrics Maximize utilization Frequent use = competency 42

43 43

44 HUB - Challenges Relationships? Infrastructure IT resources Biomed resources Partnerships with telecommunications companies Education Alignment / support Troubleshooting 44

45 SPOKE - Challenges Trust - distrust Alignment / support Education Frequency of use Troubleshooting Infrastructure IT Resources Biomed resources 45

46 Outcomes? Successful implementation in 6 locations Continued increase in referrals from these sites Decreased unnecessary transportation Improved tpa treatment in State of Alaska to 4.7 percent (national average 2-3%) Improved identification of stroke at spoke hospitals Implemented eicu at 2 sites 46

47 Future strategies? Alaska Collaborative for Telehealth and Telemedicine (ACTT) Alaska region initiative related to telehealth / telemedicine Providence Health Services system wide initiative related to outreach with subdivision for telehealth / telemedicine Robust evaluation of systems, reimbursement, infrastructure, resources, community needs 47

48 Summary Telemedicine will be a rapidly growing strategy for the delivery of healthcare throughout the United States and global communities. Through technology, access to specialized and acute care services will improve, the overall health of communities will improve and the way we deliver healthcare will change. 48

49 Questions? Dr. Christie Artuso Director, Neuroscience Services Providence Alaska Medical Center (907)

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